Effects of Iyengar Yoga on Measures of Cognition, Fatigue, Quality of Life, Flexibility, and Balance in Breast Cancer Survivors: A Case Series

ABSTRACT Introduction: Studies have revealed the benefits derived from yoga which includes improvements in quality of life (QOL) and decreased symptoms for women with breast cancer. Studies to date have not included specific measures of cognition with various interventions to improve QOL during survivorship. This case series tests the feasibility and use of yoga to determine perceived cognitive change and QOL in breast cancer survivors postchemotherapy. Methods: At baseline, participants completed the CogState computerized program to measure cognition in addition to the Perceived Cognition Questionnaire (PCQ). Quality of life instruments included: Functional Assessment of Cancer Therapy- Breast Cancer (FACT-B) and Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) while symptom surveys captured neurotoxicity through Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) and fatigue via Functional Assessment of Chronic Illness Therapy- Fatigue (FACIT-F) and the Piper Fatigue Inventory. Physical data included Forward Reach (FR) and Sit and Reach (SR) tests. All measures were taken at baseline, 4 weeks and after 8 weeks of the Iyengar yoga program. Results: The trends of 3 participants are described in the analysis. CogState showed variability through 8 weeks in the various domains of cognition. However, the PCQ showed trends in improved perceived cognition in 2 of the 3 subjects. Our study notes that with a structured Iyengar yoga program, there were improved trends in the FACT-B, FACIT-Sp, FACT/GOG-Ntx, FACIT-F, and Piper Fatigue Inventory, Forward Reach and Sit and Reach tests. Discussion: This case series depicts trends in cognitive, physical, and QOL measures with a structured 8 week Iyengar yoga program. This case series suggests that CogState and PCQ may be measures to capture cognitive changes over time with mind-body therapies such as yoga. To strengthen the reliability of this study, a greater number of subjects are needed to determine the impact of yoga on cognition over time. This study supports the need for further research on the short and long term impact of yoga on cognition in women with breast cancer. This should encourage further comprehensive and carefully designed studies.

The American Cancer Society estimated that 1,444,920 new cancer cases were expected to be diagnosed in the United States in 2007.' Approximately 178,480 new cases of invasive breast cancer were expected to occur among women in the U.S. during 2007,' making breast cancer the most common malignancy among U.S. women.2 Most breast cancer patients have received adjuvant chemotherapy to treat the disease and survivors of breast cancer may be at risk for treatment side-effects from the chemotherapy.3,8

Cognitive dysfunction as measured by standardized testing occurs in a subset of women who receive chemotherapy for breast cancer.3 Studies comparing these women to healthy controls showed statistically significant differences, with poorer function in patients receiving adjuvant chemotherapy.4 Studies also show that higher-level doses of chemotherapy results in greater cognitive impairment.5 The neuropsychological side effects typically include memory deficits and reduced concentration, and may be evident years after treatment.2,6

Vardy, Rourke, and Tannock found that although some cancer survivors do suffer cognitive impairment after chemotherapy, determining the impairment is challenging because it is usually "subtle".7 They recommended that a balance needs to be found between comprehensive batteries and briefer tests, which need to be sensitive to mild impairment.8 Also, women who may not meet the standardized criteria of dysfunction nonetheless complain of deficits, suggesting the need for clinical evaluation especially in perceived cognition changes. This case series explores cognitive change as a primary endpoint through a descriptive analysis.

The secondary endpoints of this case series include persistent fatigue and QOL, as this may also impact cognition. Lack of sleep correlates with cognitive impairment,8,9 as well as pain intensity.10 Also, higher fatigue levels in women is related to lower QOL in physical and psychological domains during and after adjuvant breast cancer chemotherapy.5,11 To date, there have been no studies examining possible interventions to address the perceived cognition loss as a result of the neurotoxicity from chemotherapy, therefore we attempted to do so in our study.

Four domains of QOL have been identified including, physical well- being, psychological well-being, spiritual well-being, and social well being.12 Due to the physical aspects of QOL, balance and flexibility measures were included. Psychometric properties of the Forward Reach test have also been explored, and related to attention, in an elderly population.13

Fatigue is one of the most common side effects of chemotherapy, and can range from mild lethargy to feeling complete exhaustion. It is the most common side effect of cancer and its treatment, affecting 76% of patients undergoing therapy.14 Fatigue as measured by standardized testing shows 91% prevalence in women with breast cancer after chemotherapy.11 This fatigue may persist for months- even years-after treatment and coping with this persistent fatigue may interfere with QOL.15,16 Since fatigue and pain can alter cognition, this study focused on measuring the impact of an Iyengar yoga-based program on these factors. These measures were included to determine feasibility and initial efficacy of this yoga protocol on breast cancer survivors.

YOGA

The Office of Cancer Complementary and Alternative Medicine within the National Cancer Institute suggests that complementary and alternative medicine offers promise in the management of QOL and treatment-related adverse effects and calls for more research in this area.17,18 Yoga is one mind-body intervention that aims at enhancing the mind's capacity to improve physical functioning and well-being.19 As an ancient Eastern spiritual discipline, it is used increasingly among Americans today and is based in the practice of physical postures, breathing techniques, and meditation.

Iyengar yoga affects the individual on a physical mental and spiritual level and promotes increased awareness, vitality, and inner peace. The Iyengar method develops strength, endurance, and optimal body alignment, in addition to flexibility and relaxation. This method also develops self-awareness and inward reflection.25 All the poses can be modified, depending on the participant's abilities. Standing poses are emphasized at the beginning to build strength and ease of movement, increase general vitality, and improve circulation, coordination, and balance. Postures for deep relaxation and focus are introduced from the beginning to the end. Gradually and with adaptation where needed, sitting and reclining postures, forward bends, inversions, backbends, twists, arm balance, and flowing sequences are introduced.20

Recent research conducted with breast cancer patients indicates that yoga may relieve the side effects from treatment and can improve overall QOL.21-28 This yoga pilot study adds to the literature as measurements of cognitive domains are explored over time. For this study, yoga sessions were instructed for 8 weeks, twice per week for 60 minutes and included a series of general relaxation techniques, breath work, and poses (Table 1). In addition, participants performed modified versions of the yoga program, consisting of approximately 20 minute independent daily sessions (Table 1 *).

METHODOLOGY

Subjects were a sample of convenience recruited postchemotherapy treatment from AtlanticCare Regional Medical Center (ARMC) and various outpatient oncology practices in southern New Jersey. Participants were included if they had Stage I, II, or III breast cancer, were at least 18 years of age, had completed chemotherapy treatment, with or without radiotherapy, less than 6 months ago, had a perceived level of cognitive loss and persistent fatigue, and were able to understand all questionnaires and informed consent. Participants were excluded if they were currently undergoing chemotherapy treatment, had a history of chronic fatigue syndrome, chronic anemia (ie, Iron Deficiency Anemia, B12 Deficiency Anemia, and Folate Deficiency Anemia), had undergone any form of neo- adjuvant chemotherapy, were pregnant or lactating or were mentally or physically challenged. This study was approved by the appropriate Investigational Review Boards (The Richard Stockton College of New Jersey and Atlanticare Regional Medical Center) and all participants signed consent forms.

INSTRUMENTATION

Measures of Cognition

We obtained quantitative cognitive change data using a computerized CogState test and perceived cognitive changes through the use of the survey instrument, Perceived Cognition Questionnaire (PCQ). The CogState is a highly valid, reliable, quantifiable, computerized measurement of cognitive function that demonstrates sensitivity to subtle changes and minimal learning effects with repeated administration.29"31 For the design in this study, the CogState battery consisted of 7 different tasks testing the cognitive domains of attention, memory, psychomotor function/ processing speed, learning and problem solving. These tasks were presented as card games in succession against a green background. Subjects responded to tasks using keys on the keyboard. The PCQ is a psychometrically sound, 7 item questionnaire using a self-report Likert scale measuring perceived changes in cognition over time in women with stage II or III breast cancer undergoing chemotherapy.32 The PCQ is a consistent, valid, and sensitive instrument for use in research among a population of women in an outpatient urban setting with a wide range of age, education level, and type of chemotherapy.40

Measures of Fatigue, Pain and QOL

The Functional Assessment of Chronic Illness TherapyFatigue (FACIT-F) and Piper Fatigue Scale were administered to participants to quantify levels of fatigue. The FACIT-F is a 13-item, self- administered questionnaire that asks participants to rate their experience of perceived level of fatigue over the past 7 days. Scores range from 0-52, with "O" being the worst possible score and "52" being the best possible score. A lower score is correlated with a higher level of fatigue.33 The Piper Fatigue Scale is composed of 22 numerically scaled "O" - "10" items that measure 4 dimensions of subjective fatigue including behavioral/severity, affective meaning, sensory, and cognitive/mood.34 Higher scores correlate with more severe levels of fatigue.

The Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) was used to specifically assess neurotoxicity associated with chemotherapy. The Fact/GOG-Ntx is an 11 item, treatment specific subscale of FACIT, given to patients suffering neurotoxicity pain from systematic chemotherapy. Lower scores denote higher levels of neurotoxicity, with scores ranging from 0-44.35

The Functional Assessment of Cancer Therapy for people with Breast Cancer (FACT-B), was used to quantify an individual's QOL over the past 7 days. The FACT-B is a self-administered questionnaire consisting of 37 items asking participants to rate their perceived physical, social, family, and emotional well- being.36 Each item is rated on a 5-point Likert scale with total scores ranging from 0-144.37 A higher number relates to a more favorable QOL.

The Functional Assessment of Chronic Illness TherapySpiritual Well-Being scale (FACIT-Sp) was used to explore the domain of spirituality, as yoga has a spiritual intention. The FACIT-Sp is a 12-item questionnaire designed to measure important components of spirituality including sense of meaning in one's life, harmony, and peacefulness. Questions on the FACIT-Sp are based on a 5 point scale. Higher values indicate a higher level of spiritual well- being.38

Physical Measures of Balance and Stability

The Functional Reach Test (FR) and Sit and Reach Test (SR) were used to quantify balance and flexibility, respectively. The FR test examines the balance of individuals with respect to the inverted cone and the patient's limits of stability. Each subject is instructed to flex the test arm forward to 90[degrees] and to reach forward as far as possible before taking a step. The subject's reach is determined by the total excursion, measured in centimeters, of the third metacarpal from the starting point (with the hand held in a fist) to the point just before balance is lost. The average of 3 measurements is used as the subject's final score.39 The FR has been shown to possess predictive validity for falls.40 People who reach, at least 10 inches are at lowest risk for falls, 6 to 10 inches are 2 times more likely to fall than those beyond 10 inches, and less than 6 inches are 4 times more likely to fall than those beyond 10 inches. People with no reaching ability are 8 times more likely to fall than those with a reach over 10 inches.41

The SR test measures hamstring and low back flexibility. Subjects are asked to maintain a long-sit position on the floor, while safely reaching forward as far as possible.42 Shoes are removed, feet are flat against the table, and legs are straight. It has established norms by the American College of Sports Medicine.43 The difference between the start and end point is then measured and recorded in centimeters. For both the FR and SR, higher values are correlated to increased limits of stability and flexibility, respectively.

Because cognition can be affected by each of the above components, improvements in cognition can be inferred with improvements in the above domains. All measures were completed at baseline, 4 weeks and 8 weeks. Each participant was within 6 months of completion of treatment and complained of "chemo fog" or cognitive alteration since the start of treatment.

RESULTS

Three of the 6 participants completed the entire 8 week program. Of the 6, only one was a minority all others were Caucasian. Descriptive aspects of each of the participants demonstrate heterogeneity in characteristics and medication intake. Participant #1 was 57 years old, with a diagnosis of invasive Stage II breast cancer. She was currently taking Alface, Coreg, Flosomax, multivitamin, and calcium. She had several lumpectomies and chemotherapy for 20 weeks and radiation for 12 weeks. She reported walking 1 to 2 miles 4 times per week. Participant # 2 was 55 years old, with invasive Stage I breast cancer. She was currently taking Nasonex and received allergy shots bi-weekly. She was treated with a lumpectomy and chemotherapy for 8 weeks and radiation for 6 weeks. She reported that her activities included normal household activities when she "feels up to it." Participant #3 was 67 years old, with Stage II breast cancer. She was currently taking Herceptin, Coreg, Benecar, Lipitor, Lexapro, and Allegra. Prior to her cancer diagnosis, this patient was taking an antidepressant and her dosage remained stable throughout treatment and in survivorship. She was treated with a lumpectomy and chemotherapy for 14 weeks and radiation for 7 weeks. She reported performing no activities.

The remaining 3 participants began the study with initial intake information but dropped out of the study before any follow-up information could be obtained. Participant #4 had to drop out of the study because she was unable to continue with yoga classes due to a knee injury that occurred 3 weeks into the program (unrelated to the yoga intervention). Participant #5 was unable to continue the study because of a painful breast reconstruction process and family health issues. Participant #6 was unable to be reached and did not respond to multiple messages regarding the follow-up. Although 3 participants completed the study, not all completed all measures at 4 weeks and 8 weeks. Last observation carried forward (LOCF) statistics was applied when participants completed baseline and 4 week measurements.44 Last observation carried forward is a widely adopted strategy for dealing with incomplete longitudinal data. When the last observation for a subject is missing in a longitudinal study, LOCF uses the most recent actual measure as though it were unchanged. Values for missing responses are inputted using observations from the most recently completed assessment.45

CogState Computerized Program Results

Mean reaction times for correct responses were calculated for each task relative to each subject. A logarithmic (log 10) transformation was then applied to determine speed of performance scores. A standard deviation of Log 10 transformed reaction was then calculated to determine variability/consistency of performance scores. Arcsine transformations were applied to the proportion of correct response to normalize the data distributions and determine accuracy of performance scores. The goal of these data is to explore changes over time. The purpose of the CogState battery is not to diagnose or compare with norm referenced data but, rather, to determine whether the women got better or worse within the 8 week yoga intervention.

Participant 1

The results of the CogState testing for Participant 1 showed improvements from baseline to measurements at 8 weeks post in the following areas: Speed of performance improved in areas of visual learning, memory, strategic problem solving, attention, and executive function (Table 2). Consistency of performance improved in areas of visual learning, memory, attention, executive function, and psychomotor function. Accuracy of performance improved with attention, strategic problem solving/recall, and executive function. All other areas tested had decreased scores for this case at 8 weeks. There were 2 areas with significant improvement for this case. The first area was strategic problem solving (PRD) and recall (PRR) both of which improved in both speed and accuracy of performance at 8 weeks. The second area of significant improvement for Participant 1 was working memory and attention (ONB) which is also classified as executive function. This area improved in speed, consistency, and accuracy of performance at 8 weeks from baseline.

Participant 2

The results of the CogState cognitive testing for Participant 2 showed improvements from baseline to measurements at 8 weeks post in the following areas: Speed of performance improved in areas of attention and psychomotor function/processing speed (Table 2). Consistency of performance improved in areas of strategic problem solving/recall, psychomotor function, processing speed, and visual attention/vigilance. Accuracy of performance improved in areas of visual learning, memory, psychomotor function, processing speed, and visual attention/vigilance. All other areas tested had decreased scores for this case at 8 weeks. The most significant area for Participant 2 was psychomotor function/processing speed (DET) showing improvements in speed, consistency, and accuracy of performance at 8 weeks. Participant 3

The results of the CogState cognitive testing for Participant 3 showed improvements from baseline to measurements at 8 weeks post in the following areas: Speed of performance improved in areas of attention, strategic problem solving/recall, memory/ executive function, visual attention, and vigilance (Table 2). Consistency of performance improved in areas of attention and strategic problem solving. Accuracy of performance improved in strategic problem solving and remained the same at 8 weeks for recall and psychomotor function/processing speed. All other areas tested had decreased scores for this case at 8 weeks. The most significant improvement for Participant 3 was strategic problem solving/recall (PRR) improving with speed and consistency of performance while remaining unchanged in accuracy of performance at 8 weeks.

As a group (n=3) the most significant areas of improvement were strategic problem solving, attention, and psychomotor function/ processing speed (Table 2). Consistency of performance improved in areas of visual learning, attention, strategic problem solving/ recall, and psychomotor function/processing speed. Accuracy of performance improved in areas of working memory, attention, and strategic problem solving recall. No change was noted in areas of visual attention and vigilance (ONB) at 8 weeks.

Perceived cognitive function, as measured by the PCQ (Figure 1), improved in Participants #1 and #2 from baseline to 4 weeks, and 4 weeks to 8 weeks. Perceived cognitive function was maintained from baseline to 4 weeks and 4 weeks to 8 weeks for Participant #3.

QOL Results

Perceived physical, social, family, and emotional well-being, as measured by the Fact-B (Figure 2), declined in Participants #1 and #3 from baseline to 4 weeks, and again from 4 weeks to 8 weeks. In Participant #2, it improved from baseline to 4 weeks, but declined from 4 weeks to 8 weeks.

Fatigue, as measured by the FACIT-F (Figure 3), declined in Participant #1 from baseline to 4 weeks, and again from 4 weeks to 8 weeks. In Participant #2, it was maintained from baseline to 4 weeks, and then improved from 4 weeks to 8 weeks. In Participant #3, it declined from baseline to 4 weeks, and was maintained at 8 weeks. Fatigue, as measured by the Piper Fatigue Scale (Figure 4), improved in Participant #1 between baseline and 8 weeks. However, it increased between baseline and 4 weeks. In Participant #2, fatigue decreased between baseline and 4 weeks, and then even further between 4 weeks and 8 weeks. Fatigue increased in Participant #3 between baseline and 4 weeks, and was maintained between 4 weeks and 8 weeks.

Spiritual well-being, as measured by the FACIT-Sp (Figure 5), increased in Participant #1 from baseline to 4 weeks, but declined from 4 weeks to 8 weeks. In Participant #2, it improved from baseline to 4 weeks, and then improved further from 4 weeks to 8 weeks. In Participant #3, it declined from baseline to 4 weeks, and was maintained from 4 weeks to 8 weeks.

Quality of life, as measured by the FACT/GOG-Ntx (Figure 6), declined for Participant #1 between baseline and 4 weeks, and from 4 weeks to 8 weeks. In Participant #2, QOL increased from baseline to 4 weeks and was maintained from 4 weeks to 8 weeks. All women expressed the continued use of yoga as it relates to QOL. They were adherent 50% to 80% of the time for the yoga home based program. The subjective reporting of participation in the home yoga exercises is not consistently valid, but it is interesting to note that these woman experienced value in the group yoga sessions and this resulted in continued practice at home.

Cognition has many components including attention, concentration, verbal ability, memory (short and long term memory, verbal and visual memory, and working memory) processing speed, and executive function. The goal of measuring cognition quantitatively and subjectively provide distinctions in a cancer survivor's self- assessment and self-concept. Although women may measure within norm- referenced scores on various cognitive tests, they may still have a perceived change as a result of their cancer treatment. There are multiple factors and variables that can impact cognition and must be accounted for in research: previous treatment type (chemotherapy, radiation); pre- and postmenopausal status of participants; mastectomy or lumpectomy; stage of cancer; tumor type. Although we did not directly measure mood or depression, self-report of cognition may be highly confounded by patient anxiety and depression.8 One recent study found that cognition correlates significantly with higher depression scores46 and only a subgroup of women who received adjuvant chemotherapy for breast cancer developed impaired cognitive performance. These individuals should be studied further, to determine why they are more vulnerable than others in being detrimentally affected by adjuvant chemotherapy, and whether depression plays a major or minor role in the development of cognitive impairment.50

In another study by the same author, prior to chemotherapy, women with breast cancer show subtle but reliable impairment in attention and learning. They found that chemotherapy treatment was associated with a minor slowing in psychomotor function and attention. Chemotherapy-related cognitive impairment was infrequent and did not correlate with subjective cognitive impairment.47 As a group, our research showed improvement in attention and psychomotor function with the integration of a yoga-based program.

Physical therapists often use brief, sensitive instruments to screen patients for cognitive impairment. The Mini Mental State Exam and High Sensitivity Cognitive Screen (HSCS) may be used by clinicians but in a recent study, the HSCS was not recommended for longitudinal studies of cancer patients with short intervals between testing due to practice effect.48 There is poor correlation between the patients' perception of their cognitive impairment and the objective tests. Therefore, prudent use of screening tools is necessary to capture clinically relevant information for optimal patient care.

In our study, although there was objective assessment of cognitive function using batteries of standardized tests, we do not have sufficient number of subjects to explore significant changes in these domains. However, the primary aim of this study was to determine the feasibility of quantitative and subjective report of cognition over time. The trends noted in the CogState analysis showed variability in the progression through 8 weeks in the various domains of cognition. However, the PCQ showed trends in improved perceived cognition in 2 of the 3 subjects. To strengthen this work however, a greater number of subjects are needed to determine the impact of yoga on cognition over time.

The instruments of fatigue, pain, and QOL appear to be sensitive to change with an 8 week yoga intervention, however each of these measures individually and collectively may culminate in cognition changes over time. Since these women were at least within 6 months since treatment ended, certainly the absence of active chemotherapy and/or radiation may have a temporal effect on changes over time with the use of yoga. A control group is needed to determine definitively the absolute changes as a result of yoga. Finally, yoga has been used to improve flexibility and balance in other populations;49,50 however, much of the research has been on prevention of falls in the elderly and chronic pain patients. No research to date has explored these measures in a breast cancer population, especially as it relates to peripheral neuropathies potentially caused by various chemotherapy agents.51

Use of spiritual and/or religious practices to cope with illness and adversity has often been incorporated into chronic disease management. Yoga includes a spiritual component which was explored in this research. Although other domains of spiritual or religious practices were not studied in depth with each participant, there was little change over time noted on the FACT-Sp. This may be due to the fact that meditation practice requires a longer training period than 8 weeks. In a recent study, the yoga intervention was 12 weeks and the result showed significant spiritual changes.22 Further investigation into the acute and long-term impact of yoga on spirituality is needed.

Various therapeutic interventions may be available for the treatment of cognition.7 The few studies that have explored the effect of yoga on cognition for various populations have mixed findings and this may be due to study design and methodological issues.52-55 Further research is needed in the areas of assessment and treatment of cognitive changes in a subgroup of cancer survivors. Not all clinics have access to computerized testing such as the CogState and appropriate referrals are necessary when perceived cognition decline is noted by the patient and therapist.

LIMITATIONS

There are several limitations of this study. Initially, it was intended as a cohort pilot study, however, there was a large drop out in the study population and we presented the data in a case series format. Therefore, baseline measurement of stability were not included in the 3 cases presented, thus violating the integrity of case series format. Clinical relevance was not measured in this study, as the primary goal was to explore the feasibility of the measures and intervention, however this should be assessed in future studies. The yoga intervention may have been too short to show specific training effects. A recent study investigated the effects of a 12-week yoga intervention on 128 patients (42% African American, 31 % Hispanic) recruited from an urban cancer center and concluded that a yoga protocol was associated with beneficial effects on social functioning. This study also suggested that individuals not receiving chemotherapy at the time of the intervention had enhanced mood, QOL, emotional, spiritual, and social well-being.22 Another 7-week pilot study explored the effects of yoga on physical and psychological benefits in breast cancer survivors and concluded that more studies were needed involving a longer duration in a randomized, controlled trial.24 In our case series, breast cancer survivors experiencing an 8-week yoga program appears to enhance cognition and may serve to buffer deterioration in both overall and specific domains of QOL.

One implicit goal of our research was to recruit minority breast cancer survivors in southern New Jersey. Only one yoga-based trial has focused on minority participation in research thus far.22 Overall, participation rates in cancer clinical trials are low for minorities, ranging from 3% to 20% of eligible participants.56- 57 Due to such a high minority population in the southern New Jersey community, and because breast cancer is the most common malignancy among US women,58 future studies will have a major impact on breast cancer survivorship and QOL in this population.

CONCLUSION

Several studies have identified that adjuvant chemotherapy in association with other standard interventions for breast cancer is associated with cognitive impairment in a subset of patients; however, the magnitude of this impairment, as well as a clear description of the characteristics of this subset of individuals, remain unclear.3'7 Overall, results suggest that women who undergo adjuvant chemotherapy as treatment for breast cancer may experience subtle yet consequential cognitive decline.7 In our case series, we studied breast cancer survivors within 6 months of treatment and changes in CogState may be more apparent during active treatment. However, the results of CogState measurements were sensitive to residual cognitive issues. Measures of fatigue, pain, and QOL as well as balance and flexibility were able to capture changes over time with the use of Iyengar yoga.

Future studies must further explore effective and sensitive methods to measure persistent cognitive impairment in women with breast cancer as well as the short and long term impact of yoga on cognition in this population. Our study noted trends in various cognitive and QOL measures with a structured Iyengar yoga program. This should encourage further comprehensive and carefully designed studies.

This case series suggests that CogState and PCQ may be measured to capture cognitive changes over time with mindbody therapies such as yoga. All confounding factors, such as age, education, intelligence quotient (IQ), fatigue and depression, hormonal therapy, and other treatments should be controlled within future study designs. Research is needed to verify a more detailed yoga protocol including frequency, intensity, and type of yoga and period of time the activity should be carried out before significant results can be expected. Key components that increase adherence to yoga protocols and any adverse events that may occur due to the incorporation of yoga in this population should also be noted. Clinical significance, which was not measured in our study, should also be assessed in future studies using functional outcome measures. It is hoped that the results of such studies will allow medical professionals to contemplate effective prevention, treatment, and rehabilitation for cognitive changes during and after treatment, for women living with breast cancer.

ACKNOWLEDGEMENTS

The authors would like to thank Clinical Research Nurses of Atlanticare Regional Medical Center (ARMC): Louise Baca, RN and Linnea Brown, RN for their dedication to recruitment for this study and Dr. Sonia Gonsalves from the Richard Stockton College of NJ (RSC) for statistical assistance. We are especially grateful to Dr. Angi Caveney and Dr. Marina Falleti for their assistance in the technical planning of the CogState battery of tests and for the generous use of the computerized system in this research.

19. National Center for Complementary and Alternative Medicine: What is Complementary and Alternative Medicine (CAM)? National Institutes of Health; 2007. Available at: http://nccam.nih.gov/ health/whatiscam/pdf/whatiscam.pdf.

23. Demark-Wahnefried W. Move onward, press forward, and take a deep breath: can lifestyle interventions improve the quality of life of women with breast cancer, and how can we be sure? J Clin Oncol. 2007;25:4344-4345.